Volume 46, No. 2 | Inequality in health

The idea of personal responsibility is a prominent feature of political and ethical debates about health and healthcare. One to understand this is that if people are responsible for living a lifestyle which means considerable risk to their health, they must bear the consequences. Though intuitively appealing, the idea of personal responsibility in health has met strong opposition. It is often suggested that it overlooks social determinants in health and would leave the imprudent to a harsh fate or introduce intrusive measures to access and determine the extent of people’s contribution to their own bad health. A natural entry point to this discussion is the choice sensitive theory of luck egalitarianism. This enables a discussion of whether and to what extent different ways of holding people responsible for the consequences of their risky choices avoid the criticisms often raised against personal responsibility in health. However, it turns out that the appeal of the different approaches is very much dependent on the contexts in which we seek to introduce them.

In her famous article “The concepts and principles of equity and health”, Margaret Whitehead defines inequity in health as “a variance in health status that is avoidable, unnecessary and seems unfair in the context of what is going on in the rest of the society”. I argue that this definition is implausible; that welfare luck egalitarianism should be our ideal of distributive justice; that at the most fundamental level people are never responsible for anything in such a way that appeals to individuals’ own responsibility can justify inequalities in welfare; and finally that social inequality in health is a problem since it correlates with inequality in welfare no matter which (plausible) theory of welfare we apply.

People’s life-styles or their health choices importantly affect their general health. Furthermore, there is a social gradient in these choices such that people in relatively disadvantageous social positions tend to make worse choices with regard to their health than people in more advantageous positions. The consequence is deep inequalities in health. The state, to the extent it is part of its role to prevent harm and to reduce inequality, appears obliged to try to influence people’s health choices in the interest of their own health and general well-being. However, the state acting to prevent people from harming themselves is notoriously controversial, at least to liberals. It amounts to paternalism – something liberals have traditionally been loath to accept. Furthermore, the equality-generating credential of the available policy measures is in some cases doubtful. To assess the problem of paternalism in relation to government efforts to change life-styles, partly with the aim of reducing inequalities in health, we need a clear notion of paternalism. The latter may, roughly, be seen as follows: A acts paternalistically in relation to B, if, and only if, (a) A restricts B’s liberty; (b) A does so against B’s will; (c) A does so in B’s interest; (d) A’s behavior cannot be justified without counting its beneficial effects to B in its favor. According to this conception, when the government informs citizens of the danger involved in certain types of health-related conduct, it is not acting paternalistically. However, campaigns may in fact increase rather than decrease inequality of health (because the worse off are less responsive to such measures than the better off). Nudging, on the other hand, stands a better change of reducing inequality in health. However, nudging policies are less uncontroversial in term of the problem of paternalism than their proponents are inclined to think. More familiar measures aiming to make the health-endangering behavior more expensive and/or difficult or outright prohibiting it stand a good chance of reducing inequalities, whilst not being more controversial than nudging policies (perhaps less) in terms of the paternalism they involve.

Lasse Nielsen | Fair equality of opportunity and health

Norman Daniels’ theory of “Just Health” is among the most comprehensive and acclaimed theories of distributive justice in health and health care. At the heart of Daniels’ theory is the extension of Rawls’ principle of fair equality of opportunity to concern also inequalities in opportunities related to different states of health. Although fairly plausible, Daniels’ theory does face some problems. First, it relies on a flawed definition of health. Second, it lacks a sound argument for the importance of its suggested central health needs. Finally, it does not succeed in accounting for the special importance of health. Drawing on elements from Amartya Sen’s Capabilities Approach, Daniels’ theory can be bolstered to deal with these problems and, thus, the outlook for fair equality of opportunity in regard to health and health care would be significantly strengthened.

Thomas Søbirk Petersen | Too old for treatment? Should women over 45 have access to artificial insemination?

Should it be legal for health care professionals in the Danish healthcare system to help women over 45 with assisted reproductive techniques such as in vitro fertilization, which is illegal according to Danish law? The article conducts a critical discussion of central arguments for and against the law. Arguments for the law are based on premises that emphasize the concern for mother and child and that the present law aims to regulate behavior in a way that encourages women to have children while they are young. Arguments against the law emphasize that the law is contrary to a central egalitarian principle in the Danish healthcare system and one of the UN’s human rights. The article concludes that, based on an analysis of the discussed arguments, there are good moral and pragmatic reasons to change the current Danish law to make assisted reproduction for women over 45 legal.

The Danish municipal reform in 2007 increased the average population size in the Danish municipalities significantly. Ahead of the reform, the Structure Commission, which composed the grounds for the decision of the reform, predicted that there would be no democratic consequences of the suggested amalgamations. Based on a cross-sectional study with data from the 2009 Municipal Election we question this assertion. Specifically, we examine the correlation between municipal size and citizens’ perception of external political efficacy. This is interesting because external political efficacy is known to express a diffuse commitment to the political system, which is central to the legitimacy of a democratic government. We find that the perception of external political efficacy is lower in large municipalities, which challenges the Structure Commission's conclusions.

Kurt Houlberg | David and Goliath with the fingers in the till before closing time. Debt and liquidity management in Danish municipalities facing amalgamation

The Danish Structural Reform in 2007 amalgamated 239 municipalities into 66 municipalities while leaving 32 municipalities unchanged. For municipalities facing amalgamation the tax base of the new amalgamated municipality represents a common pool resource, and in order to prevent opportunistic behavior before closing time the national government took a number of regulatory initiatives in the pre-reform years. Differentiating between political incentives in a continuous common pool context and an amalgamation pool context, this article utilizes a Difference-in-Difference design and empirically finds that the national initiatives were not sufficient to prevent amalgamating municipalities from draining liquid assets and increasing long-term debt before closing time. Opportunistic behavior was pervasive, especially the last year before amalgamation and especially in the smaller municipalities of each amalgamation.